Healthcare Provider Details

I. General information

NPI: 1346567013
Provider Name (Legal Business Name): MODUPE R ADEDOJA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RAFATU YISA

II. Dates (important events)

Enumeration Date: 04/21/2010
Last Update Date: 12/14/2023
Certification Date: 12/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 W MONROE ST STE 300
PHOENIX AZ
85003-1718
US

IV. Provider business mailing address

111 W MONROE ST STE 300
PHOENIX AZ
85003-1718
US

V. Phone/Fax

Practice location:
  • Phone: 205-536-8400
  • Fax:
Mailing address:
  • Phone: 281-725-7671
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP138574
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF346956
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number288675
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number405441
License Number StateNY
# 5
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number288675
License Number StateAZ
# 6
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number628238
License Number StateNY
# 7
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number875172
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: